Here's an Idea... Address Health Care Costs

An article in today's Wall Street Journal (Insurer Aims to Alter Health-Care Fee Model) discusses a new, well somewhat new, approach to paying health care providers. Instead of fee for service, which some say implicitly discourages health care providers from keeping people healthy (the more people are sick, the more medical care they need, and the more providers are paid), Blue Cross Blue Shield of Massachusetts is setting up a payment plan that encourages providers to keep people healthy. This is very similar to an idea suggested in the Innovator's Prescription – apply the right business model to the service you are providing to rein in health care costs. Clayton Christensen in that book also suggests that the government is probably the worst positioned of all key players in the health care industry to be able to effect any real effective change.


The current efforts in congress to reform health care, OK let's be honest it's really health care insurance “reform” we're talking about here, is the classic case of providing solutions when we really don't understand the problem. We keep hearing that the goal of health care reform is to reduce health care costs and to increase coverage. The 2,074 page plan in the senate apparently will increase the number of covered individuals by 31 million, but the plan is projected to cost over $850 billion... not sure that is what I would define as controlling costs. What it does represent is a common problem exhibited by many projects; we start a project to deliver a shiny new solution, but we can't really explain what problem we are trying to solve, or if we can identify the problem, we can't quite connect how the shiny solution actually addresses the problem. Throw in the dysfunctional motivations of national politics, and you can forget about any semblance of a clear connection between problem and solution.

I'm not naive enough to think that anything will change in Washington DC anytime soon, other than the makeup of congress after the 2010 elections, but at least I hope this entire boondoggle can be an object lesson to Project Practitioners regarding understanding the problem that you are trying to solve before coming up with a solution. A guy can dream, can't he?

Vignettes from Apollo 13 Related to Decision Making

Here are more Apollo 13 vignettes that didn't make the cut for Stand Back and Deliver.

Less than two days into the flight of Apollo 13, the crew experiences a major malfunction in the service module. Mission control quickly assesses the situation and realizes that their purpose has changed. No longer are they focused on landing two of the astronauts on the moon, they are now solely focused on getting all three astronauts safely back to earth. That also means that there is a lot of activities originally planned for this mission that they were simply no longer going to do. This was dramatized particularly well in the movie Apollo 13 when Ed Harris playing Gene Krantz, one of the flight directors, tosses the flight plan aside, “I want you all to forget the flight plan. From this moment on, we are improvising a new mission.” The team then proceeded to discuss what they were and were not going to do. Most of the activities surrounded the bare minimum activities to get the astronauts safely home. The level of activity was also restricted through a consideration of what risks they faced, for example choosing to sling shot around the moon in a “free return trajectory” instead of firing up the main service module engine to immediately turn around because the did not know if the service module engine would work. They also had to make a series of assumptions based on the actual capabilities of the spacecraft, paying attention to what it was designed to do, but realizing they had to test it’s limits. And finally, they weighed the various constraints on resources and time that faced the astronauts to decide what activities the astronauts could and should do.

During the Apollo 13 mission, the Mission Control faced the when do we do things decision point several times. Once it was realized that the spacecraft had been damaged, the normal flight plan, which in itself was a prioritized list of activities, gave way to a new list of activities. The first thing to do was get the crew to safety within the spacecraft itself. With the available oxygen and power quickly disappearing in the command module, the crew had to move themselves into the lunar module to use it as a lifeboat. Next activity, get the crew on the appropriate trajectory to return home. After that, Mission Control had to work out a means for using the lithium hydroxide filters from the command module in the lunar module, a classic square peg in a round hole problem. Throughout the mission, Mission Control and the crew kept a keen eye on all of the activities that needed to be done and quickly determined the priority of each, with an obvious understanding that it did no good to get the spacecraft back to earth if there was not enough oxygen, water, or power, or too much Carbon Dioxide to keep the crew alive.

Teams will often utilize a value model without realizing it. Gene Krantz and the rest of the ground crew and astronauts for the Apollo 13 mission gave little thought to the concept of a Value Model, but they were in fact utilizing one. They started out with the purpose of landing men on the moon. With some pretty substantial costs, some soft benefits of reinforcing the United States’ domination of space and the opportunity to do additional exploration of the moon’s surface. Then the considerations changed, which changed the value they sought from the mission, and thereby changed the decisions that they made.

Your teams most likely do not have the life and death consequences or the public exposure experience by the Apollo 13 mission, but they can still utilize this model to make informed decisions about the right things to do and when to do them.

The close alignment of the Apollo program’s purpose to the country’s strategy at the time was a key to it’s success in the face of so many odds. To see what happens when that compelling tie between purpose and strategy disappears one only has to look at the space program since those heady days in 1969 and 1970. Starting with the end of the Apollo program, once the USSR had been beaten, landing on the moon became almost routine, people began to loose interest, and the value derived from such missions began to fade. In fact the last couple of missions of a program designed, at least subconsciously, to beat the Soviet Union to the moon ended up cooperating them in joint space missions that added no real value other than to point out that the two countries could actually cooperate on something if they set their mind to it.

The shuttle program has proven unable to capture the imagination of the American public, or perhaps more importantly, Congress. The program started out seeking a way to provide reliable, convenient, regular trips to space using a reusable spacecraft. But when the realities of the program hit and NASA found that the shuttle could not economically provide regular or reliable trips to space, other purposes were sought out for the shuttle. Much in the way that some projects come about as solutions looking for problems, the shuttle was bounced from one possible use to another, until recently when NASA made the decision to seek the moon and mars again, and to ride the horse that brought them here

As the comparison between the Apollo and Space Shuttle programs shows, purpose alignment plays an important role in deciding whether an activity is worth pursuing.

Thinking back to the Apollo 13 mission again, the mission controllers and astronauts were facing some definite considerations when it came to making decisions about the actions to take in the mission. The mission itself, even before the oxygen tank explosion, was inherently risky given the extreme environment of space thru which the crew was flying. They also faced some very clear constraints in the form of oxygen, potable water, power, physical space, and materials with which to operate. They also had to factor in several assumptions that were made designing the Apollo craft, and had to make additional assumptions as plans were developed to bring the astronauts safely home.

Perhaps one of the most compelling aspects of the Apollo 13 mission is how these considerations changed throughout the mission. The risks that were present and known at the beginning of the mission were different, some having come to fruition, and new ones being discovered as a result of the events of the mission. The astronauts faced a risk of electrocution when trying to power up the command module because of all the condensation that occurred in the module while it was powered down for several days. The constraints placed on the astronauts changed dramatically when Oxygen Tank #2 exploded a couple of days into the mission. They no longer had sufficient power to stay in the command module, they were restricted to drinking 5oz of water a day, and they were limited to roughly 12 amps of power for most of the trip back from the moon, which is less power than what a typical household vacuum uses. All of these changes impacted the decision making process of the ground crew and astronauts, and also impacted the idea of what was considered successful and valuable.

Friendship 7 and Real Options

We face a lot of decisions in the course of a project. One thing we often don't put much thought to is the appropriate time to actually make the decision. A case where the time to decide was quite clear occurred on the flight of Friendship 7, John Glenn’s Mercury flight in February of 1962. The flight was planned for three orbits. At the end of the first orbit, Mission Control was just about to patch John F. Kennedy through to John Glenn when Mission Control received a “Segment 51” warning and John Glenn began having altitude control problems. Mission Control told the President that they were a little busy at the moment and would have to call him back. The team then turned to figuring out what Segment 51 indicated.

Segment 51 is meant to indicate that the landing bag had deployed. The landing bag is a rubber bag that inflated on the Mercury capsule following reentry which prevented the capsule from sinking when it landed in the ocean for recovery. The landing bag was situated behind the heat shield which is what protected the Mercury capsule from the intense heat of reentry. If the landing bag had truly deployed, that also meant that the heat shield had been pried loose from the capsule, which was not a good thing for John Glenn. Basically it meant that if they were to believe what the data was telling them, the Mercury Capsule could burn up during reentry.

Mission Control immediately began reviewing their options. As it turned out, the Mercury Capsule had a retropack strapped on to the bottom of the capsule that fired three rockets to slow the capsule into a reentry velocity and then was jettisoned before the capsule entered the atmosphere. The retropack was attached to the capsule by three metal straps and if left on would theoretically hold the heat shield on during the crucial point of reentry. But Mission Control was not sure if the retropack burning up would also cause damage to the heat shield. They also weren’t sure whether the Segment 51 alert was actually valid. Some on the team thought the issue was actually an electrical issue, basically a false alarm.

With two orbits left, Mission Control began a series of activities at once. Some controllers began working to determine tests that they could perform to determine whether the indicator was an electrical issue or if the heat shield had actually dislodged. Others started working trying to figure out what would happen if the retropack stayed attached to the capsule, and still others were figuring out how the reentry procedures needed to change if in fact they decided to leave the retropack on. All the while, no decisions had been made whether to leave the retropack on, Mission Control in fact had two more orbits to figure that out, and they were using every bit of that time to explore their options, and gather their information to help make their decision.

Chris Kraft, the flight director for the mission was convinced that the problem was an electrical issue, and stalled making the decision to leave the retropack on until the last moment so that he could have as much information as possible:

“Kraft was still holding out until the last moment, so that he had a complete understanding of the final instructions before he radioed up to John Glenn. The mission was turning into a horse race. Kraft wanted answers from one final test to be performed over Hawaii before he turned the discussion to the entry procedure modifications.” Failure is Not an Option p.74

Finally after hearing that the retropack rockets fired and were not a risk to explode during reentry, Walter Williams, the Operations Director and Kraft’s boss made the decision to leave the retropack on at the point in time where Mission Control and John Glenn had enough time to alter the reentry procedure to not jettison the retropack

When Glenn reentered the atmosphere, the retropack burned up, followed by the heat shield sufficiently protecting Glenn from the heat of reentry. After Glenn landed and analysis was done on the recovered capture, it was determined that the Segment 51 reading was invalid.

This story about Glenn’s first orbital flight shows the power of real options, in today’s world of uncertainty and complexity. We do not always know the answers, but by knowing what information would be helpful for making a decision, and having a fairly good idea of how long we have to make that decision, we can be much better prepared to decide at the right time.